MED SURG HESI 2022 (A+)

MED SURG HESI 2022 (A+) The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat? - ANS-Inflate the cuff Rationale: If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. The nurse has implemented a bowel maintenance program for an unconscious client. The nurse would evaluate the plan as best meeting the needs of the client if which method was successful in stimulating a bowel movement? - ANS-Glycerin suppository Rationale: The least amount of invasiveness needed to produce a bowel movement is best. Use of glycerin suppositories is the least invasive method and usually stimulates bowel evacuation within a half-hour. A client is readmitted to the hospital with dehydration after surgery for creation of an ileostomy. The nurse assesses that the client has lost 3 lb of weight, has poor skin turgor, and has concentrated urine. The nurse interprets the client's clinical picture as correlating most closely with recent intake of which medication, which is contraindicated for the ileostomy client? - ANS-Biscodyl Rationale: The client with an ileostomy is prone to dehydration because of the location of the ostomy in the gastrointestinal tract and should not take laxatives The client is complaining of skin irritation from the edges of a cast applied the previous day. Which action should the nurse take? - ANS-The nurse petals the edges of the cast with tape Rationale: minimize skin irritation. The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? - ANS-"Are you experiencing pain in your joints?" Rationale: Hyperparathyroidism is associated with over secretion of parathyroid hormone (PTH), which causes excessive osteoblast growth and activity within the bones. When bone reabsorption is increased, calcium is released from the bones into the blood, causing hypercalcemia. The bones suffer demineralization as a result of calcium loss, leading to bone and joint pain CONTINUES...